Midwest Multistate Division
3809-33528100APPROVED PROVIDER APPLICATIONOne (1) email* containing four Adobe.pdf files (*not to exceed 5 MB in size) of the Approved Provider Application package requirements and applicable Application review fee must be submitted to the Midwest Multistate Division (Midwest MSD) Office by February 1st, June 1st or October 1st. The entire application package must be received by the deadline. Agencies unable to meet the deadline due to unusual or extenuating circumstances, may request a one-time extension from the Midwest MSD, which may or may not be granted. Requests for extensions must be submitted to the Midwest MSD office 30 days prior to the application deadline for consideration. Extensions will not be granted after that date. Application packages received after the deadline, without prior arrangements with the Midwest MSD, will not be accepted for that cycle. For additional guidance in completing the Approved Provider Application, please refer to the Midwest MSD website for instructions, tools and resources available.Please note: The Approved Provider Application package consists of a total of four separate, collated Adobe.pdf files – one of the Approved Provider Application and supporting documentation and one for each sample activity.The appropriate Application review fee must accompany the Application package for the review process to begin. Please also ensure a copy of this page is included in your submission to aid in processing. The review process takes four months to complete (Example: Applications submitted by February 1st will be considered for a June 1st approval start time). Provider approval is granted for a three-year period.If you have any questions, please contact the Midwest MSD Nurse Peer Review Leader at NPRL@ or the Midwest MSD Office by email to questions@ or by phone to 573-636-4623 ext. 102.Application Review Fee: (Based on type of Provider below)$2,000.00Single Agency Provider (see definition in Application instructions)$4,800.00System Provider (see definition in Application instructions)Applicant Information:Organization Name:Name of Approved Provider Unit (if different):Address:City:State:Zip Code:Primary Nurse Planner Name:Phone:Preferred Email:Contact for Application:If same as Primary Nurse Planner indicate “Same as above”Phone:Preferred Email:New Applicant? ? Yes ? NoPayment:? Check (payable to the Midwest Multistate Division or Midwest MSD)? Credit Card – Visit the Midwest Multistate Division Website at to Pay via Credit CardPROVIDER APPROVAL CRITERIAThe following five sections are required written documentation for new Approved Provider applicants and those organizations currently approved as providers reapplying to maintain their provider approval status:Approved Provider Organizational Overview (OO)Approved Provider Criterion 1: Structural Capacity (SC)Approved Provider Criterion 2: Educational Design Process (EDP)Approved Provider Criterion 3: Quality Outcomes (QO)Approved Provider Criterion 4: Sample Activities (SA)Please respond to each of the Criterion and corresponding sections with a narrative response to demonstrate Approved Provider adherence. Approved Provider Criterion 1-3 require a process description and an example illustrating how the process is operationalized within the Provider Unit. Criterion 4 requires the submission of three sample activities held in the previous 12-month period. Please utilize the Application Instructions document available on the Midwest MSD website at for specific details on how to write and prepare your Approved Provider Application package for submission. Approval decisions are determined based on compliance with the ANCC/Midwest MSD Accreditation criteria. In order to validate compliance, it is essential that the Midwest MSD review team receive a comprehensive, well-organized Approved Provider Application, including narrative descriptions for each criterion, sample activity files demonstrating compliance and supplemental evidence as required or requested. Validation of compliance is based on the written documentation provided in this Provider Application.Approved provider CRITERIA Organizational Overview (OO)The Organizational Overview (OO) is an essential component of the application process that provides a context for understanding the Approved Provider Unit/organization. The applicant must submit the following documents and/or narratives:Organizational OverviewDemographicsOO1.a Submit an executive statement and/or high-level strategic summary of the Approved Provider Unit, including but not limited to how the Provider Unit functions, the mission of the Provider Unit as it relates to its Nursing Continuing Professional Development/Continuing Nursing Education offerings, including the impact the Provider Unit has on the organization and its learners (1000-word limit). System Providers: Please include details about your Provider Unit demographics i.e. listing of facilities comprising the system Provider Unit.Description: FORMTEXT ????OO1.b Is the Approved Provider Unit part of a larger, multi-focused organization? ? Yes ? NoIf yes, please describe the relationship of these scope dimensions to the total organization.Description: FORMTEXT ????Lines of Authority and Administrative SupportOO2.a Submit a list of the names, credentials, positions, and titles of the Primary Nurse Planner, and other Nurse Planner(s) (if any) in the Approved Provider Unit. Primary Nurse Planner:Nurse Planner(s):? Please see the attached Nurse Planner Biographical data forms for the Primary Nurse Planner and Nurse Planner(s)OO2.b Submit position descriptions for the Primary Nurse Planner and Nurse Planners (if any) in the Approved Provider Unit. ? Please see the attached position description(s) for the Primary Nurse Planner and Nurse Planner(s) on Page # FORMTEXT ????? The Primary Nurse Planner assures that the position descriptions are specific to the individual’s role and responsibilities to their position within the Approved Provider UnitEducational Design ProcessData Collection and Reporting – Approved Provider organizations report data, at a minimum, annually to their ANCC Accredited Approver, which includes the following:OO3.a Submit a completed listing of all CNE offerings provided in the past 12 months (see required date ranges below), including, at a minimum: activity dates; activity titles; target audience; total number of nurses who successfully completed each activity; total number of nursing contact hours offered for each activity; if the activity was jointly provided; any commercial support received (monetary & in-kind amounts).Activity Reporting Date Ranges:February 2021 applicants: January 1, 2020 – January 1, 2021June 2021 applicants: May 1, 2020 – May 1, 2021October 2021 applicants: September 1, 2020 – September 1, 2021Please choose from one of the submission options below:? Activity data for the required reporting period was entered into the NARS Annual Reporting System.? Our organization is a new applicant. Please see the attached sample activity documentation for the three activities planned, implemented, and evaluated during the twelve (12) months prior to Application submission. Were these three activities individually approved by the Midwest MSD? ? Yes ? No (please select one)APPROVED PROVIDER CRITERION 1: Structural Capacity (SC)The capacity of an Approved Provider is demonstrated by commitment to, identification of, and responsiveness to learner needs; continual engagement in improving outcomes, accountability, leadership, and resources. Applicants will write narrative statements that address each of the criteria under Commitment, Accountability, and Leadership to illustrate how structural capacity is operationalized.Each narrative must include a specific example that illustrates how the criterion is operationalized within the Provider MITMENT: The Primary Nurse Planner demonstrates commitment to ensuring RNs learning needs are met by evaluating Approved Provider Unit processes in response to data that may include but is not limited to aggregate individual educational activity evaluation results, stakeholder feedback (staff, volunteers), and learner/customer feedback. Describe and, using an example, demonstrate the following:The Primary Nurse Planner’s (PNP’s) commitment to learner needs, including how Approved Provider Unit processes are revised based on aggregate data, which may include but is not limited to individual educational activity evaluation results, stakeholder feedback (staff, volunteers), and learner/customer feedback.Description of Process: FORMTEXT ????Example: FORMTEXT ????ACCOUNTABILITY: The Primary Nurse Planner is accountable for ensuring that all Nurse Planners in the Approved Provider Unit adhere to the ANCC/Midwest MSD Accreditation criteria. Describe and, using an example, demonstrate the following:How the Primary Nurse Planner ensures that all Nurse Planner(s) of the Approved Provider Unit are appropriately oriented/trained to implement and adhere to the ANCC/Midwest MSD Accreditation criteria. Description of Process: FORMTEXT ????Example: FORMTEXT ????LEADERSHIP: The Primary Nurse Planner demonstrates leadership of the Approved Provider Unit through direction and guidance given to individuals involved in the process of assessing, planning, implementing, and evaluating CNE activities in adherence to the ANCC/Midwest MSD Accreditation criteria. Describe and, using an example, demonstrate the following:How the Primary Nurse Planner/Nurse Planner provides direction and guidance to individuals involved in planning, implementing and evaluating CNE activities in compliance with ANCC/Midwest MSD Accreditation criteria. Description of Process: FORMTEXT ????Example: FORMTEXT ????APPROVED PROVIDER CRITERION 2: Educational Design Process (EDP)The Approved Provider Unit has a clearly defined process for assessing educational needs as the basis for planning, implementing, and evaluating CNE. CNE activities are designed, planned, implemented, and evaluated in accordance with adult learning principles, professional education standards, and ethics. Examples for the narrative component of the Provider Application (EDP 1-7) may be chosen from, but are not limited to, those contained in the sample activity files. All elements should have a corresponding narrative response, unless otherwise specified in the criterion, showing Approved Provider adherence. Evidence must demonstrate how the Approved Provider Unit complies with each criterion.Each narrative must include a specific example that illustrates how the criterion is operationalized within the Provider Unit.ASSESSMENT OF LEARNING NEEDS: CNE activities are developed in response to, and with consideration for, the unique educational needs of the target audience.Describe and, using an example, demonstrate the following:The process used to identify a problem in practice or an opportunity for improvement (professional practice gap).Description of Process: FORMTEXT ????Example: FORMTEXT ????How the Nurse Planner identifies the underlying educational needs (knowledge, skills, and/or practice(s)) that contribute to the professional practice gap. Description of Process: FORMTEXT ????Example: FORMTEXT ????PLANNING: Planning for each educational activity must include one Nurse Planner and one other planner. One of the planners must have appropriate subject matter expertise for the educational activity. Planning for each educational activity must be independent from the influence of commercial interest organizations. Describe and, using an example, demonstrate the following:How the Nurse Planner identifies, and measures change in knowledge, skills, and/or practices of the target audience that are expected to occur as a result of participating in the educational activity.Description of Process: FORMTEXT ????Example: FORMTEXT ????The process used to identify and resolve all conflicts of interest (COI) for all individuals in a position to control educational content (planning committee, presenters, authors, and content reviewers).Description of Process: FORMTEXT ????Example: FORMTEXT ????EFFECTIVE DESIGN PRINCIPLES: The educational design process incorporates identified gap(s), measurable learning outcomes, best available evidence, and appropriate learner engagement strategies. Describe and, using an example, demonstrate the following:How the content of the educational activity is developed based on best-available, current evidence (e.g. clinical guidelines, peer-reviewed journals, experts in the field) to foster achievement of desired outcomes.Description of Process: FORMTEXT ????Example: FORMTEXT ????How strategies to promote learning and actively engage learners are incorporated into educational activities. Description of Process: FORMTEXT ????Example: FORMTEXT ????EVALUATION: A clearly defined method that includes learner input is used to evaluate the effectiveness of each educational activity. Results from the activity evaluation are used to guide future activities. Describe and, using an example, demonstrate the following:How the summative evaluation data for an educational activity are used to analyze the outcomes of that activity and guide future activities.Description of Process: FORMTEXT ????Example: FORMTEXT ????APPROVED PROVIDER CRITERION 3: Quality Outcomes (QO)The Approved Provider Unit engages in an ongoing evaluation process to analyze its overall effectiveness in fulfilling its goals and operational requirements to provide quality CNE. Each narrative must include a specific example that illustrates how the criterion is operationalized within the Provider Unit.APPROVED PROVIDER UNIT EVALUATION PROCESS: The Approved Provider Unit must evaluate the effectiveness of its overall functioning as an Approved Provider Unit. The Approved Provider Unit must also demonstrate how its structure and processes result in positive outcomes for itself and for registered nurses participating in its educational activities. Describe and, using an example, demonstrate the following:The process utilized for evaluating the overall effectiveness of the Approved Provider Unit in carrying out its work as a provider of nursing continuing professional development.Description of Process: FORMTEXT ????Example: FORMTEXT ????Approved Provider Unit Quality OutcomesQO2.a Identify at least one of the quality outcomes the Approved Provider Unit has established and worked to achieve over the past twelve months to improve Provider Unit operations, including the metrics used to measure success in achieving that outcome.Quality Outcome: FORMTEXT ????Metrics to Measure Achievement: FORMTEXT ????Describe and, using an example, demonstrate the following:QO2.b Using the quality outcome identified in QO2.a, explain how the most recent Approved Provider Unit self-evaluation process, described in QO1, resulted in the development and/or improvement of this identified outcome for Provider Unit operations, including how that outcome was measured and analyzed.Description of how Outcome was Determined by Self-Evaluation: FORMTEXT ????Description of how Outcome was Measured and Analyzed: FORMTEXT ????VALUE/BENEFIT TO NURSING PROFESSIONAL DEVELOPMENT: The Approved Provider Unit must evaluate data to determine how the Approved Provider Unit, through the learning activities it has provided, has influenced the professional development of its nurse learners. Professional Development Quality OutcomesQO3.aIdentify at least one of the quality outcomes the Approved Provider Unit has established and worked to achieve over the past twelve months to improve the professional development of nurses, including the metrics used to measure success in achieving that outcome. Quality Outcome: FORMTEXT ????Metrics to Measure Achievement: FORMTEXT ????Describe and, using an example, demonstrate the following:QO3.b Using the quality outcome identified in QO3.a, explain how the most recent Approved Provider Unit self-evaluation process, described in QO1, resulted in the development and/or improvement of this identified outcome to improve the professional development of nurses, including how that outcome was measured and analyzed.Description of how Outcome was Determined by Self-Evaluation: FORMTEXT ????Description of how Outcome was Measured and Analyzed: FORMTEXT ????APPROVED PROVIDER CRITERION 4: Sample Activities (SA)As a component of the educational design process and final component of the Approved Provider Application package, the Approved Provider applicant will select and submit three (3) samples of NCPD activity files in their entirety that have been planned and implemented within 12 months of the Approved Provider Application and comply with the ANCC/Midwest MSD Primary Accreditation criteria.Current/Renewing Providers: Please submit three sample activity files demonstrating adherence to the accreditation criteria in effect at the time the activity was provided. Each educational activity must:Be a separate and distinct event, at least one contact hour (60 minutes) in lengthHave been fully planned, implemented, and evaluated at least onceBe the entire activity file (not a portion of an activity, or one day of a three-day activity)Not have been previously submitted or designed using previously developed content. Sample activities should be representative of the types of activities offered by your Approved Provider Unit. If your Unit is not able to meet the requirements, please contact the Midwest MSD office.If in the last 12 months, the:APU jointly provided an educational activity, submit the activity file from such an eventAPU awarded contact hours for an enduring activity of 1 hour or more, submit the activity file from such an event APU received commercial support for an activity, submit the activity file from such an eventSystem Provider APUs, newly formed or existing, the sample activity files cannot all be from the same facility. Please select three activities from different facilities within the system to submit with the application. New Applicants: New applicants must have three activities approved by the Midwest MSD or another ANCC Accredited Approver during the twelve (12) months prior to Application submission. Each educational activity must:Be a separate and distinct event, at least one contact hour (60 minutes) in lengthHave been provided at least once and include summative evaluation data and participant listing/rosterBe the entire activity file (not a portion of an activity, or one day of a three-day activity)Not have been jointly provided, previously submitted, or designed using previously developed content. The activity files for these three activities must be submitted with the Provider Application package and demonstrate adherence to the accreditation criteria in effect at the time the activity was provided. Please also submit a template of a certificate that will be given to participants upon completion of the Provider Unit’s educational programs once Approved Provider status has been granted. Use the following provider approval statement on your certificate template:(Name of your organization) is approved as a provider of nursing continuing professional development by the Midwest Multistate Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.Please see the NCPD Activity Planning Guide for assistance in documentation for the sample activities. Remember, each activity file must be submitted as a separate PDF file and it is recommended that applicants include a table of contents, providing a page number, and/or PDF bookmarks to guide reviewers through all corresponding supporting documentation.Sample Activity #1title of activity:Activity Format: ? Live ? Enduring ? Blendeddate & Location of activity:Sample Activity #2title of activity:Activity Format: ? Live ? Enduring ? Blendeddate & Location of activity:Sample Activity #3title of activity:Activity Format: ? Live ? Enduring ? Blendeddate & Location of activity: ................
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